Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 May 1:17:2681-2696.
doi: 10.2147/JIR.S456590. eCollection 2024.

Tibial Cortex Transverse Transport Facilitates Severe Diabetic Foot Wound Healing via HIF-1α-Induced Angiogenesis

Jie Liu #  1 , Xiajie Huang #  1 , Hongjie Su  1 , Jie Yu  1 , Xinyu Nie  1 , Kaibing Liu  1 , Wencong Qin  1 , Yongxin Zhao  1 , Yongfeng Su  1 , Xiaocong Kuang  2 , Di Chen  3 , William W Lu  4 , Yan Chen  1 , Qikai Hua  1
Affiliations

Tibial Cortex Transverse Transport Facilitates Severe Diabetic Foot Wound Healing via HIF-1α-Induced Angiogenesis

Jie Liu et al. J Inflamm Res. .

Abstract

Purpose: Management of severe diabetic foot ulcers (DFUs) remains challenging. Tibial cortex transverse transport (TTT) facilitates healing and limb salvage in patients with recalcitrant DFUs. However, the underlying mechanism is largely unknown, necessitating the establishment of an animal model and mechanism exploration.

Methods: Severe DFUs were induced in rats, then assigned to TTT, sham, or control groups (n=16/group). The TTT group underwent a tibial corticotomy, with 6 days each of medial and lateral transport; the sham group had a corticotomy without transport. Ulcer healing was assessed through Laser Doppler, CT angiography, histology, and immunohistochemistry. Serum HIF-1α, PDGF-BB, SDF-1, and VEGF levels were measured by ELISA.

Results: The TTT group showed lower percentages of wound area, higher dermis thickness (all p < 0.001 expect for p = 0.001 for TTT vs Sham at day 6) and percentage of collagen content (all p < 0.001) than the other two groups. The TTT group had higher perfusion and vessel volume in the hindlimb (all p < 0.001). The number of CD31+ cells (all p < 0.001) and VEGFR2+ cells (at day 6, TTT vs Control, p = 0.001, TTT vs Sham, p = 0.006; at day 12, TTT vs Control, p = 0.003, TTT vs Sham, p = 0.01) were higher in the TTT group. The activity of HIF-1α, PDGF-BB, and SDF-1 was increased in the TTT group (all p < 0.001 except for SDF-1 at day 12, TTT vs Sham, p = 0.005). The TTT group had higher levels of HIF-1α, PDGF-BB, SDF-1, and VEGF in serum than the other groups (all p < 0.001).

Conclusion: TTT enhanced neovascularization and perfusion at the hindlimb and accelerated healing of the severe DFUs. The underlying mechanism is related to HIF-1α-induced angiogenesis.

Keywords: HIF-1α; angiogenesis; diabetic foot; distraction osteogenesis; tibial cortex transverse transport.

PubMed Disclaimer

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
This schema shows the study design and the assessments at each stage. In the control group, surgery including induction of hindlimb ischemia and creation of DFU was performed 4 weeks after diabetes induction. In the TTT group, in addition to hindlimb ischemia induction and DFU creation, tibial corticotomy was performed, external fixator was attached, and the corticotomized segment was transversely distracted. The distraction phase consisted of 6 days of medial transport followed by 6 days of lateral transport. At the end of the transport, the corticotomized fragment returned to its original position and the external fixator was removed. In the sham group, all the procedures were the same as the TTT group except that the corticotomized segment would not be distracted.
Figure 2
Figure 2
Procedure of TTT. (A) Four weeks after diabetes induction, the femoral artery (blue arrow) was exposed and ligated to induce hindlimb ischemia; and the incision was sutured. (B) A longitudinal 3-cm incision was made on the anteromedial aspect of the upper 1/3 of the calf, then the soft tissue was retracted and the periosteum was exposed. (C) Corticotomy (10 mm in height and 4 mm in width) was performed by drilling multiple successive unicortical holes (green arrow). Two 0.8-mm pins were inserted into the osteotomized fragment for transport while two 1.0-mm pins into the tibial shaft for anchor of the custom-made external fixator. The multiple drilling holes were connected using a small bone chisel to separate the cortex from the tibial shaft. (D and E) The external fixator was assembled and the incision was closed. (F–H) A rectangular wound (20 mm in length and 10 mm in width) was created by removal of full-thickness skin and subcutaneous tissues on the dorsum of foot. (I) Postoperative radiograph was taken to conform the sites of corticotomy (red arrow) and pins.
Figure 3
Figure 3
These postoperative radiographs show a tibia that underwent TTT. (A) The corticotomy and external fixator sites (arrow) were confirmed on radiographs immediately after surgery. (B) After 3 days of medial transport, the displacement of the corticotomized fragment was evident. (C) At day 6, the corticotomized fragment reached its maximum displacement. (D and E) This was followed by 6 days of lateral distraction, at the end of which (day 12) the corticotomized fragment returned to its original position and the external fixator was removed.
Figure 4
Figure 4
TTT promoted DFU healing. (a) Representative images of ulcer healing progress at day 3, 6, 9, and 12, respectively, for the three groups. (b) Mean area of DFU in the three groups during observation. *p < 0.05, **p < 0.01, ***p < 0.001, TTT vs Control; #p < 0.05; # #p < 0.01, TTT vs Sham; Tukey’s multiple comparison test.
Figure 5
Figure 5
Representative histology images of the three groups at day 6 and 12, respectively. (a) In haematoxylin and eosin (H&E) staining, better continuous epidermis was observed in the TTT group than the other groups. Some hair follicle-like tissue was present in the TTT group. (b) Quantitative analysis showed higher dermis thickness in the TTT group than the other groups. (c) In Masson trichrome staining, more collagen was evident in the TTT group than the other groups. Some hair follicle-like tissue was present in the TTT group, too. (d) Quantitative analysis showed higher percent of collagen content in the TTT group than that of the other groups. Scale bar 200 μm. Data were presented as means (standard deviations); **p < 0.01, ***p < 0.001. TTT vs Control or Sham, Tukey’s multiple comparison test.
Figure 6
Figure 6
TTT elevated local perfusion. (a) The images demonstrated perfusion changes of the hindlimb after TTT at day 6 and 12, respectively. The color bar represents perfusion levels. (b) The TTT group showed the highest blood perfusion (perfusion unit, PU) among the three groups. ***p < 0.001 for TTT vs Control or TTT vs Sham, at day 6 or 12; Tukey’s multiple comparison test.
Figure 7
Figure 7
TTT promoted hindlimb neovascularization. (a) The images demonstrated changes in neovascularization of the hindlimb after TTT as detected using CTA at day 6 and 12, respectively. (b) The TTT group showed the highest vessel volume among the three groups. Scale bar: 5 mm. ***p < 0.001.
Figure 8
Figure 8
Concentrations of HIF-1α and downstream angiogenic factors in serum after TTT. (A) The levels of PDGF-BB in the TTT group were higher than the other two groups at day 3, 6, 9, and 12, respectively. (B) The TTT group had higher concentrations of serum SDF-1 than the other two groups at day 3, 6, 9, and 12, respectively. (C) The levels of serum VEGF in the TTT group were higher than the other two groups at day 3, 6, 9, and 12, respectively. (D) The TTT group displayed higher concentrations of SDF-1 in serum than the other two groups at day 3, 6, 9, and 12, respectively. Data were measured as means (standard deviations). ***p < 0.001, Tukey’s multiple comparison test.
Figure 9
Figure 9
TTT promoted angiogenesis in the healing wound of DFU. (a) Representative immunohistochemistry images of CD31+ cells and VEGFR2+ cells in the three groups at day 6 and 12, respectively. (b) Quantitative analysis showed higher expression of CD31 in the TTT group than the other groups. (c) Representative immunohistochemistry images of VEGFR2+ cells in the three groups at day 6 and 12, respectively. (d) Quantitative analysis displayed higher expression of VEGFR2+ cells in the TTT group than the other groups. Scale bar 100 μm. Data were presented as means (standard deviations), *p < 0.05, **p < 0.01, ***p < 0.001. TTT vs Control or Sham, Tukey’s multiple comparison test.
Figure 10
Figure 10
Elevated activity of HIF-1α, PDGF-BB, SDF-1, and VEGF in diabetic wound after TTT. (a) Representative immunohistochemistry images of HIF-1α expression in the three groups at day 6 and 12, respectively. (b) Quantitative analysis showed higher expression of HIF-1α+ in the TTT group than the other groups. (c) Representative immunohistochemistry images of PDGF-BB expression in the three groups at day 6 and 12, respectively. (d) Quantitative analysis displayed higher expression of PDGF-BB in the TTT group than that of the other groups. (e) Representative immunohistochemistry images of SDF-1 expression in the three groups at day 6 and 12, respectively. (f) Quantitative analysis demonstrated higher expression of SDF-1 expression in the TTT group than the other groups. Scale bar 100 μm, 100 × magnification. Data were presented as means (standard deviations), **p < 0.01, ***p < 0.001. TTT vs Control or Sham, Tukey’s multiple comparison test.
Figure 11
Figure 11
Schematic of the potential mechanism of DFU treatment using TTT. In response to transverse distraction, osteogenic activity (differentiation of bone marrow mesenchymal stem cells into osteoblasts) is elevated, leading to a localized hypoxic microenvironment. This triggers the expression of HIF-1α which in turn induces formation of multiple angiogenic factors such as VEGF, PDGF-BB, and SDF-1. These downstream factors promote angiogenesis and neovascularization to supply oxygen, nutrients, and critical signals for the newly formed bone and also carry away the metabolic wastes. Simultaneously, HIF-1α, VEGF, PDGF-BB, and SDF-1 travel through the trans-cortical capillaries into peripheral circulation and eventually reach the site of DFU, which is in hypoxic status and with low levels of HIF-1α, VEGF, PDGF-BB, and SDF-1. Similar to their effect in the bone transport site, these factors induce angiogenesis (differentiation of endothelial progenitor cells into endothelial cells) and neovascularization at the wound and improves the hypoxic status, ultimately resulting in ulcer healing.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Sun H, Saeedi P, Karuranga S, et al. IDF Diabetes Atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabet Res Clin Pract. 2022;183:109119. doi:10.1016/j.diabres.2021.109119 - DOI - PMC - PubMed
    1. Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Clin Infect Dis off Publ Infect Dis Soc Am. 2023:ciad527. doi:10.1093/cid/ciad527 - DOI - PubMed
    1. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet Lond Engl. 2005;366:9498. doi:10.1016/S0140-6736(05)67698-2 - DOI - PubMed
    1. M K, F M, Ajm B, S E. Etiology, epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care. 2023;46(1). doi:10.2337/dci22-0043 - DOI - PMC - PubMed
    1. van Netten JJ, Bus SA, Apelqvist J, et al. Definitions and criteria for diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2023:e3654. doi:10.1002/dmrr.3654 - DOI - PubMed

Grants and funding

This study was supported by grants from National Natural Science Foundation of China (82060406, 82360429, 82260448), Natural Science Foundation of Guangxi (2022JJA141126), Guangxi Key Research and Development Plan (2021AB11027), Advanced Innovation Teams and Xinghu Scholars Program of Guangxi Medical University, China Postdoctoral Science Foundation (2019M650235), Key R&D Project of Qingxiu District, Nanning, Guangxi (2021003), Clinical research climbing plan of the First Affiliated Hospital of Guangxi Medical University (YYZS2020010).

LinkOut - more resources